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What is cardiotocography?
Cardiotocography (CTG) is used during pregnancy to monitor both the fetal heart and contractions of the uterus. It is most commonly
used in the third trimester. Its purpose is to monitor fetal well-being and allow early detection of fetal distress. An abnormal CTG
indicates the need for more invasive investigations and potentially emergency caesarian section.
How it works
The device used in cardiotocography is known as a cardiotocograph.
It involves the placement of two transducers onto the abdomen of a pregnant woman.
The CTG is then assessed by the midwife and obstetric medical team.
To interpret a CTG you need a structured method of assessing its various characteristics.
The most popular structure can be remembered using the acronym DR C BRAVADO
11/6/2017 How to read a CTG | Geeky Medics
DR – Define Risk
C – Contractions
V – Variability
A – Accelerations
D – Decelerations
O – Overall impression
Define risk
You first need to assess if the pregnancy is high or low risk.
This is important as it gives more context to the CTG reading (If the pregnancy is high risk, the threshold for intervention will likely
be lower.)
Some reasons a pregnancy may be considered high risk are shown below ¹
Gestational diabetes
Hypertension
Asthma
Obstetric complications
Multiple gestation
Postdate gestation
Previous cesarean section
Intrauterine growth restriction
Premature rupture of membranes
Congenital malformations
Oxytocin induction/augmentation of labour
Pre-eclampsia
Contractions
Next, you need to record the number of contractions present in a 10 minute period.
Each big square on the example CTG chart below is equal to 1 minute, so look at how many contractions occurred within 10
big squares.
Individual contractions are seen as peaks on the part of the CTG monitoring uterine activity.
11/6/2017 How to read a CTG | Geeky Medics
.²
In this example, there are 2-3 contractions in a 10 minute period (this is often referred to as “3 in 10”)
Look at the CTG and assess what the average heart rate has been over the last 10 minutes.
Fetal tachycardia
Fetal tachycardia is defined as a baseline heart rate greater than 160 bpm.
Fetal hypoxia
Chorioamnionitis – if maternal fever also present
Hyperthyroidism
Fetal or maternal anaemia
Fetal tachyarrhythmia
Fetal bradycardia
Fetal bradycardia is defined as a baseline heart rate less than 100 bpm for 3 minutes or more.
Postdate gestation
Occiput posterior or transverse presentations
Severe prolonged bradycardia (< 80 bpm for > 3 minutes) indicates severe hypoxia.
Variability
Baseline variability refers to the variation of fetal heart rate from one beat to the next.
Variability occurs as a result of the interaction between the nervous system, chemoreceptors, baroreceptors and cardiac
responsiveness.
It is, therefore, a good indicator of how healthy a fetus is at that particular moment in time, as a healthy fetus will constantly
be adapting its heart rate in response to changes in its environment.
To calculate variability you look at how much the peaks and troughs of the heart rate deviate from the baseline rate (in bpm).
Reassuring – 5 – 25bpm
Non-reassuring:
Abnormal:
..
Fetal sleeping – this should last no longer than 40 minutes (most common cause)
Fetal acidosis (due to hypoxia) – more likely if late decelerations are also present
Fetal tachycardia
Drugs – opiates / benzodiazepines / methyldopa / magnesium sulphate
Prematurity – variability is reduced at earlier gestation (<28 weeks)
Congenital heart abnormalities
Reduced variability 5
Accelerations
Accelerations are an abrupt increase in the baseline fetal heart rate of greater than 15 bpm for greater than 15 seconds. ¹
Decelerations
Decelerations are an abrupt decrease in the baseline fetal heart rate of greater than 15 bpm for greater than 15 seconds.
There are a number of different types of decelerations, each with varying significance.
Accelerations
Early deceleration
Early decelerations start when the uterine contraction begins and recover when uterine contraction stops.
This is due to increased fetal intracranial pressure causing increased vagal tone.
It therefore quickly resolves once the uterine contraction ends and intracranial pressure reduces.
Variable deceleration
Variable decelerations are observed as a rapid fall in baseline fetal heart rate with a variable recovery phase.
They are variable in their duration and may not have any relationship to uterine contractions.
They are most often seen during labour and in patients’ with reduced amniotic fluid volume.
When pressure on the cord is reduced another acceleration occurs and then the baseline rate returns.
Accelerations before and after a variable deceleration are known as the “shoulders of deceleration”.
Their presence indicates the fetus is not yet hypoxic and is adapting to the reduced blood flow.
The presence of persistent variable decelerations indicates the need for close monitoring.
Variable decelerations without the shoulders are more worrying as it suggests the fetus is becoming hypoxic.
Variable deceleration 5
Late deceleration
Late decelerations begin at the peak of the uterine contraction and recover after the contraction ends.
This type of deceleration indicates there is insufficient blood flow to the uterus and placenta.
As a result, blood flow to the fetus is significantly reduced causing fetal hypoxia and acidosis.
Maternal hypotension
Pre-eclampsia
Uterine hyperstimulation
The presence of late decelerations is concerning and fetal blood sampling for pH is indicated.
If fetal blood pH is acidotic it indicates significant fetal hypoxia and the need for emergency C-section.
11/6/2017 How to read a CTG | Geeky Medics
Late deceleration 5
Prolonged deceleration
Prolonged deceleration 5
Sinusoidal pattern
11/6/2017 How to read a CTG | Geeky Medics
Overall impression
Once you have assessed all aspects of the CTG you need to give your overall impression.
Reassuring
Suspicious
Abnormal
The overall impression is determined by how many of the CTG features were either reassuring, non-reassuring or abnormal.
The NICE guideline below demonstrates how to decide which category a CTG falls into.4
11/6/2017 How to read a CTG | Geeky Medics
References
1. http://www.aafp.org/afp/990501ap/2487.html
2. http://www.fastbleep.com/medical-notes/o-g-and-paeds/16/34/449
3. Clinical obstetrics and gynaecology. 2nd Edition. 2009. B.Magowan, Philip Owen, James Drife
5. http://www.brooksidepress.org/Products/Military_OBGYN/Textbook/LaborandDelivery/electronic_fetal_heart_monitoring.htm